Top 3 Strategies for Building Your Proven

Blueprint for Pathways to Success

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Today's Presenters
Daniel Marino, Managing Partner, Lumina Health Partners
Dan specializes in shaping strategic initiatives for healthcare organizations and
senior healthcare leaders. His specialties include population health management,
clinical integration, physician alignment, and health information technology.

Maha Salah-Ud-Din, MPH, Senior Advisor, Lightbeam Health

Solutions
Maha has been responsible for the implementation and “go live” of enterprise
population health management software in over 15 accountable care organizations,
representing nearly 1 million patient lives. Since beginning her time at Lightbeam, Maha
has developed extensive value-based care playbooks, ACO roadmaps, and other advisory
program initiatives while providing exceptional support for her clients.

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About Lumina Health Partners
• Recognized industry leaders at Lumina Health Partners work closely with
clients as they optimize their program performance to meet the standards of
value-based care.
• Our proven strategies enable medical organizations to realize
measurable strategic, financial, and operational goals to achieve the Triple
Aim.
• Along with advising these provider organizations about operations and
governance matters, we help drive cultural change within the environment.
• Lumina actively engages physicians and leadership with our exclusive “Lead
to Support” model.

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Advisory Services

VALUE-BASED STRATEGY DIGITAL INNOVATION CLINICAL LEADERSHIP AND

• Strategic planning AND ANALYTICS TRANSFORMATION GOVERNANCE
• CIN and ACO formation, • HIT advisory and selection • Service line optimization • Culture transformation
assessment, and • Data governance • Practice assessments and • Physician executive
optimization • Advanced analytics and improvement mentoring and coaching
• Provider network reporting • Clinical variation • Leadership development
development • Analytics infrastructure and • Value-based and quality programs
• Managed care strategy network development payment programs • Change management
development and • Digital Innovation • Lumina Leadership Institute
contracting
• Care management and
clinical redesign

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About Lightbeam Health Solutions
Claims / Services

Expertise Performance
Deep PHM roots Reliable data accuracy
Strong intellectual capital Actionable business intelligence
Progressive vision Scalable across entire populations
Proven results Deliver rapid patient outcomes

Comprehensive Partnership
Unified solution focus Proactive client management
End-to-end PHM platform Strategic/consultative approach
Best-in-class advisory services Highly responsive/collaborative
Seamless EHR integration Risk management/mitigation

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 About Lightbeam Health Solutions

23.6 6.6 2.2 $471

Million Billion Billion Million Technology
Advisory
Services
Patient Lives Clinical Data Claims In Generated
Managed Elements Processed Savings
People

NPS
56

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Agenda
• Industry overview
• Preparing for risk
• Building the blueprint for success
• Optimizing you value-based contracts

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What is Value-Based Care?
Two Conflicting Healthcare Paradigms
1. Continued pressure to bring down healthcare costs and reduce
reimbursement (volume-based model)
2. Shift to accountable care and value-based reimbursement tied to
performance of services

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The New Realities of Reimbursement
• Commercial reimbursement for FFS is either staying flat or decreasing
• PCPs: flat or slight increase from 2% to 3%
• Specialists: decreases 5% to 10%
• Pressure on hospitals to accept reimbursement at Medicare rates
• Payers are following Medicare and wanting providers to assume “risk”
• Payers will provide incentives for utilization management unless providers can
show evidence of clinical care management through quality outcomes
• The providers taking steps to prepare for “risk” will be best positioned for it

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Market Perspective on VBC
• VBC is here to stay; the market has shifted from
FFS to FFV
• Medicare is sending consistent signals to expand
VBC payment models and commercial payers
• All commercial payers have ACO/VBC programs
to transfer risk with intent toward narrow, high-
performing networks

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VBC Shift: US Projected Payment Data
US 2018* US PROJECTED*
FFS
20%

Population
Health FFS
34% 41% Populatio
n
Health
50%

FFS +
P4P
FFS + P4P 30%
25%

*2018 based on US LAN projections, FFS, and FFS +P4P estimated. Source: HCP LAN https://hcp-lan.org/groups/apm-fpt-work-products/apm-report/

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Value-Based Contracting Brings Together…
Managed lives (assigned, attributed) obtained through market
contracting activity and subject to certain performance expectations

Financial risk incentives to manage the population

Provider network attuned to the VBC “program”

VBC infrastructure to support providers in meeting contract

responsibilities

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Why Providers Need to Shift to VBC
Collaboration: VBC arrangements serve as an avenue to grow payer
Partnership relationships and partner under value-based care.

Access to New Patients: Now and in the future, payers are developing narrow
Product Growth network products around VBC arrangements, and more specifically, ACOs that
perform well under these arrangements.

Transition to Downside Risk: Most payers will agree to a reasonable

Glide Path to Risk continuum to downside risk that enables providers to develop VBC capabilities.

Access to Data / Market Data Mining: VBC arrangements provide substantial data and analytics that enable
providers to analyze their population of patients. This makes the data actionable for
Intelligence care management, patient retention, and cost efficiencies in respect to FFS.

Value-Based Payments: Shared savings provides additional opportunities to

Enhance / Preserve increase provider reimbursement from the base FFS, which is decreasing or
Reimbursement being eliminated entirely.

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The Typical Value-Based Contracts

Commercial Governmental
• Pay-For-Performance • Medicare Shared Savings
• ACO/Shared Savings Program (MSSP) ACO
• Bundled Payments • Medicare Advantage
• COE/Direct to Employer • Bundled Payments for Care
• Capitation Improvement
(BPCI)/Advanced (BPCIA)

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Preparing for Risk
Questions for Leaders as They Prepare
for Risk
• How do we know when we are ready to assume risk?
• How do we efficiently manage the shift in utilization?
• What are the most effective speed-to-market care
management programs?
• Where do start in looking at data?
• What data creates the best actionable insights?
• How do we ensure incentives are aligned (physician,
hospital, payer, patient)?

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Call to Action: Evolve to Management of Risk
Phase 1 Phase 2 Phase 3
Develop the Structure Establish Partnerships Manage Risk

• Build the organizational • Leverage infrastructure • Now a full-service provider

infrastructure with providers in new of population health
• Establish quality programs, markets services
incentive models, and • Develop products • Offer insurance products
outcome tracking • Partner with payer(s) direct to the market or
• Develop care management (carrier as the middleman) partner with major payers
infrastructure to manage professional or
– Larger provider network
global risk
• Enter into limited risk- – Access to membership
based contracts • Commoditize products and
– Direct-to-employer services, direct full-risk
contracts contracting with employers
• Advanced benefits designs

While foundational components are in place, more robust capabilities are necessary
to perform well under downside risk arrangements

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Value-Based Payment Models

Fee-for- Value- Bundled Shared Global

Pay for
Performance Based
Service Purchasing Payments Savings Payments

• Health Plans • Physicians

• Gov’t Payers • Medical
Risk Shift Groups
• Employers
• Hospitals

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Key Components of a Risk-Based Contract
• Minimum contract elements to best balance risk and return
• Transparency
• Timing of risk transfer
• Attribution methodology
• Quality funding
• Stop loss
• Market cost trends
• Reporting/reconciliation

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Key Drivers of Successful ACO Arrangements
Building the Key Drivers
information- Patients
management Cost-of-care (PMPM)
platform from the
data, to the
information, to the
Risk Adjustment
knowledge is the
foundation of a
good value-based Provider/Member
contract. Attribution Value-Based
Contract
Payers
Quality Measures and Products
Care Management

Data Sharing

Shared Savings
Calculation Employers

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VBC Elements and Processes
Six key areas of commercial shared savings contracts:

1. Attribution methodology/roster control

2. Risk-adjustment methodology

3. Quality parameters/measure congruence across contracts

4. Data sharing

5. Shared savings calculation methodology/risk model

6. Reconciliation/audit and appeal rights

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Building the Blueprint for Success
After You Sign the Contract, the Real
Work Begins
• Transition to a “high-performance” data
analytics organization
• Optimize provider participation
• Quantify value from a value-based
contract
• Build focus-driven care management for a
high-risk population

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 Population Health Management
Risk Stratification

High-Risk Patients
Current Focus One complex illness, multiple comorbidities
5%
Risk-Rising Patients
ACOs/CINs Chronic, aging, chronic condition -
Risk - Cost

Opportunity 15 - 30% unmanaged

to Expand
Market
Services &
Low-Risk Patients
Share
Healthy or chronic
Condition - managed
65 - 80%

Population

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Successful Implementation of VBC
Reimbursement
Implementation Infrastructure Integration

• Capabilities required for success:

• Strong executive leadership with a clear vision and unwavering focus
• Strong physician leadership with a role in governance of the network
• Transparent and aligned financial accountability, tied to quality, efficiency,
and performance for all leadership and clinical providers

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Blueprint to Managing Risk
• Operationalize contract requirements
Contract Operations • Manage deliverables to payer

• Set up external joint operating committee structure

Governance • Set up internal structure with provider workgroups and committees

• Inbound: Establish data delivery and data management

HIT Inbound/Outbound • Outbound: Develop clinical data feed to payer

• Announce VBC contract and provide high-level overview with FAQs

Communication • Communicate contract requirements

• Conduct orientation sessions for providers and staff; one business/operational, one
Education clinical

• Define populations and stratify risk

Care Delivery • Engage patients, manage care, and identify clinical interventions

• Ingest and deliver payer reports, develop standard VBC reporting package
Reporting/Analytics • Measure performance and analyze opportunities to maximize contract performance

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Managing Risk through Effective Care
Management
Risk-Stratification Tool
• Consolidate data from CDR, EMR, DWH
• Analyze claims and clinical data
• Stratify patients by risk levels
• Refer to appropriate level of care

High-Risk Complex Disease

Preventive Health
Care Management Care Management Management

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Multi-Generation Plan to Achieving
Analytics Excellence
1. Analytics 2. Advance Analytics 3. Real-Time Analytics
Organization and Reporting and Applications

Governance/ Governance/ Real-Time

Definitions Definitions Information

Reporting/
Data Enhancement Predictive
Visualization

Data Needs Advanced Reporting Alerts for Action

Additional Supporting
Customer Service Technology/Tools Applications

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Data Drives Contract Performance and
Success
• Obtaining “usable” data is the top issue for
ACOs
• Access to historical claims data is key
• Maintain a consistent data format/ level of Information Knowledge
detail for “in-area, out-of-network” claims
• Compatibility with ACO’s analytic systems
• We recommend attaching specified claim
Data
file layout as part of contract

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Using Data to Drive Operational
Insights and Contract Success
Achieving a Holistic View

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Deploy Focused Pop Health Strategy

High-Risk Patient Operational

Care Coordination Effectiveness
Identification
Utilize John Hopkins ACG® Establish protocols to manage Streamline clinical effectiveness
and Lightbeam ATI (Ability to high-risk patients to reduce through workflow
Impact) to identify costly avoidable utilization and management and technology
high-risk patients with high ensure appropriate site of care enablers
ability to impact

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Focus on High-Risk/High-Spend Patients
• Identify a small percentage of the total
population to focus on for greatest
effectiveness
High-Risk Patient • Identify within that population which
Identification patients have the highest ability to impact
Utilize tools to identify
costly high-risk patients
• Analyze the identified cohort with care
with high ability to impact managers and physician staff to prioritize
care
• Focused management with high-cost
patients will increase quality of care while
reducing overall medical spend

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Focus on High-Risk/High-Cost - Example

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Focus on High-Risk/Super Utilizers

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Detailed Finance & Utilization

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Cohort Builder

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Define Effective Care Coordination Model
• Define clinical and organization problems
that you are trying to solve? How will you
solve them?
Care Coordination (ie, lower rates of ER use or hospital
admissions)
Establish protocols to
manage high-risk patients • Determine care model with existing
to reduce avoidable resources and staff, or determine
utilization and ensure expansion needs
appropriate site of care
• Create a systematic approach to identify,
assess, and engage patients and providers
• Measure and continually adapt/improve
the approach

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Care Management

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Where Complex Care Fits in your Org
Why worry about high-need, high-cost
complex patients?
Multiple
• As you move up the pyramid, the care complexity increases,
Conditions
but the return on investment grows exponentially
Acute patients with
time limited needs Where to get started?
• Stratify patients by risk and common need
Patients with single chronic
condition • Integrate medical, behavioral, and social
services
• Shift care from institutions to community
Wellness support for healthy patients

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Aim for Continuous Improvement

• Focus on quality measures that impact

Operational
Effectiveness shared savings
• Data governance and validation
Streamline clinical
effectiveness through • Utilize automation tools to drive
workflow management and engagement and patient condition
technology enablers identification

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Care Gaps
Automated Identification of
Care Gaps Delivered to
Providers

Compliance drill-down for any

Provider/Measure combination
• Performance guarantee
monitoring for all measures on
one dashboard
• Drill-down by measure
• View non-compliant patients

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HCC Coding
Automation of HCC care gaps to
ensure proper coding occurs

CMS determines health and assigns risk

to Medicare patients by looking at the
risk adjustment factor (RAF) score. You
can increase CMS funding by correctly
coding during a patient visit.
HCC codes must be recoded each year to
accurately portray your patients’ RAF
score. The HCC coding done in this
current year sets up the RAF and
subsequent funding for next year.

CMS formula for determining reimbursement:

Demographics (Age, Gender, etc.) + Sum of HCC Codes (Factor) = RAF Score

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POC Support
• Provider-facing engagement tools
• Practice/provider specific performance dashboards
• Automated tasking downstream
• Pushes Point-of-Care (POC), Face Sheet to
practice/providers
• Integrates into EMR systems via SSO
• Supports multiple forms
• Offers Remote print services

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Importance of Care Gap Closures
• Mohawk used Lightbeam to identify all
employees past-due for a mammogram.
Click for Case
• They then provided onsite mammograms Study
through mobile programs.

Employee was scheduled Had subsequent

at the on-site mobile ultrasound which detected
mammogram unit early stage breast cancer

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Annual Wellness Visits
Why AWVs

• Fee For Service Revenue - $169

new, $118 sub
• Quality measure optimization
• Better care lower spend
• Performed by non-MD
• Much of which can be done
pre-visit
• Attribution management
• Don’t lose patients – often
low spend
• Target HCC gaps

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Physician Engagement

❑ Establish strong advocacy within

organizational leadership and clinical
team
❑ Designate an executive sponsor to
champion AWV rollout and focus
❑ Create a unified vision for your organization
with respect to your overall mission and
strategic goals
❑ Identify any quality improvement efforts
you would like to result from AWV

Confiential. Please do not copy or forward.

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 Path to Advancing VBC Maturity
• Referral
management
• Invest in behavioral
• Assess HIE synergies
health integration
• Artificial intelligence
• Actively manage services
• Deploy population
high-risk/high-need • Established
patients preferred networks
health revenue
• Bolster CCM • Focus on post-acute
• Assess current protection measures
program care network
state • CCM
• Bolster Transition of
• Physician • AWV
Care Management
engagement • TCM
• Physician
alignment

High-Risk/
Organizational VBC Revenue Care Continuum Expanded Ecosystem
High-Need

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Strategic Partner
• Shared risk, shared reward
business terms
Partner
• High level of data, systems,
and operational Advisor
interdependence
Problem Solver
• Open access to C-level
executive contacts Credible Source
• Co-development of
Traditional Vendor
strategic plans

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In Summary
• Healthcare is going through a transformation with pressures in assuming risk
• Changes in healthcare delivery and bending of the cost curve will make us
more accountable
• Building a “risk responsible” organization is key
• The blueprint to managing risk must be actionable
• Adoption and integration of analytics is a big driver of change
• Aligned objectives will prepare you for accountable care

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Contact Information
www.luminahp.com

DANIEL MARINO www.twitter.com/LuminaHP

Managing Partner
www.linkedin.com/company/lumina-health-partners/
[email protected]
www.youtube.com/LuminaHealthPartners

MAHA SALAH-UD-DIN, MPH

Senior Advisor
[email protected]

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